Unique emergency supply situation

[owlegrad]

Scenario: Patient immediately needs CII drug (aka morphine) and the prescriber is out of town. Prescriber can phone in an emergency supply to the pharmacist to be deduced to writing. The quantity prescribed should not exceed the emergency period. The prescriber must then furnish a signed hard copy duplicating what was prescribed for the emergency supply period to the copy (either via mailing it to them, giving it to the patient to bring to the pharmacy {probably not the most reliable method}, or bringing it to them themselves), within 7 days of the order being transmitted via phone. If not, the pharmacist must report the prescriber to the DEA.

Feel free to correct me if you think I'm wrong.

I do not think you are wrong, but the law does not specify what an emergency is, and anything that interupts the patient's therapy could presumably qualify. That is how we learned it anyway.

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[BidingMyTime]

It sounds like a partial fill of a CII to me, regardless of the situation. I wouldn't have done it, as others have said, I'd have had the guy pay up front, then get reimbursed later. Or filled just part of the RX that he wanted, with the understanding that the remaining quantity would be lost.
I have done emergency supplies of CIII-CV (ie phenobarbitol for a guy that had been on it forever for seizures)--but it's legal to do partial fills of CIII-CV.

 

[PharmDstudent]

I do not think you are wrong, but the law does not specify what an emergency is, and anything that interupts the patient's therapy could presumably qualify. That is how we learned it anyway.

I think you're misunderstanding "an emergency" with "an emergency situation".

It states what an emergency situation is, in this state.

This is what my state's law says:
"Authorization for Emergency Dispensing
An emergency situation exists when administration of the drug is necessary for immediate treatment, an appropriate alternate treatment is not available, and the prescribing practitioner cannot reasonably provide a written prescription. In the case of an emergency situation, a pharmacist may dispense a controlled substance listed in Schedule II upon receiving oral authorization of a prescribing individual practitioner, provided that:
i. the quantity prescribed and dispensed is limited to the amount adequate to treat the patient during the emergency period (dispensing beyond the emergency period must be pursuant to a written prescription signed by the prescriber);
ii. the prescription shall be immediately reduced to written form by the pharmacist and shall contain all information described in Paragraph C.2 of this Section, except for the signature of the prescriber;
iii. if the prescriber is not known to the pharmacist, he shall make a reasonable effort to determine that the oral authorization came from a registered prescriber, which may include a callback to the prescriber using his telephone number as listed in the telephone directory or other good faith efforts to insure his identity; and
iv. within seven days after authorizing an emergency oral prescription, the prescriber shall cause a written prescription for the emergency quantity prescribed to be delivered to the dispensing pharmacist. In addition to conforming to the requirements of Subsection C of this Section, the prescription shall have written on its face "Authorization for Emergency Dispensing," and the date of the oral order. The written prescription may be delivered to the pharmacist in person or by mail, but if delivered by mail, it shall be postmarked within the seven day period. Upon receipt, the dispensing pharmacist shall attach this prescription to the oral emergency prescription which had earlier been reduced to written form. The pharmacist shall notify the nearest office of the DEA if the prescriber fails to deliver a written prescription to him within the required time; failure of the pharmacist to do so shall void the authority conferred by this paragraph to dispense without a written prescription of a prescriber."

 

[swatchgirl]

"iv. within seven days after authorizing an emergency oral prescription, the prescriber shall cause a written prescription for the emergency quantity prescribed to be delivered to the dispensing pharmacist."

Can it be an electronic script instead of a written one that the doctor has to supply within 7 days of the verbal CII order?

 

[swatchgirl]

Scenario: Patient immediately needs CII drug (aka morphine) and the prescriber is out of town. Prescriber can phone in an emergency supply to the pharmacist to be deduced to writing. The quantity prescribed should not exceed the emergency period. The prescriber must then furnish a signed hard copy duplicating what was prescribed for the emergency supply period to the copy (either via mailing it to them, giving it to the patient to bring to the pharmacy {probably not the most reliable method}, or bringing it to them themselves), within 7 days of the order being transmitted via phone. If not, the pharmacist must report the prescriber to the DEA.

Feel free to correct me if you think I'm wrong.

What if the doctor electronically sends in the script (and has it electronically signed) within 7 days instead of furnishing a signed hard copy. Will that count as an "original" script?

 

[npage148]

Yes

 

[RxPreceptor]

What if the doctor electronically sends in the script (and has it electronically signed) within 7 days instead of furnishing a signed hard copy. Will that count as an "original" script?

Cover in mail or e-Rx can both count as covers...I prefer the e-Rx cover; just inform the prescriber to put "emergency authorization for dispensing" in the MD notes section so it's not filled as a duplicate.

 

[swatchgirl]

Cover in mail or e-Rx can both count as covers...I prefer the e-Rx cover; just inform the prescriber to put "emergency authorization for dispensing" in the MD notes section so it's not filled as a duplicate.

Verbal CII orders are not limited to just the terminally ill, right? My pharmacy manager seems to think so.

 

[zelman]

Verbal CII orders are not limited to just the terminally ill, right? My pharmacy manager seems to think so.

Might vary by state. In most it wouldn't be limited that way. However, it is limited to "emergencies" as defined by nobody in particular. Your PIC may be deciding on that definition.

 

[Sine Cura]

Are there actually any chain pharmacists who would actually permit an emergency fill?

If it's an "emergency" go to the parking lot.

 

[zelman]

Are there actually any chain pharmacists who would actually permit an emergency fill?

If it's an "emergency" go to the parking lot.

In NY pre-eRx mandate I had patients who had "emergency" controlled substances called in every month.

 

[owlegrad]

I have multiple "emergency" CII's called in every day here in LTC. By contrast I never had an emergency supply called in at CVS. It is amazing how many emergency situations we have every day.

This is what my state's law says:
"Authorization for Emergency Dispensing
An emergency situation exists when administration of the drug is necessary for immediate treatment, an appropriate alternate treatment is not available, and the prescribing practitioner cannot reasonably provide a written prescription.

I don't see your point. Is there a difference between "emergency" and "emergency situation"? Isn't what you posted just the longer, more legal terminology way of saying what I said?

 

[trailerpark]

I would deny all verbal C2 orders. If it's truly an emergency they can go to the hospital down the street.


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[Claydoe]

slightly off topic, but regarding the 72 hour rule do you make the patient come back within 72 hours to complete the partial, or do you simply make sure to complete the filling of the rx within 72 hours and leave it in the waiting bin?

 

[lord999]

slightly off topic, but regarding the 72 hour rule do you make the patient come back within 72 hours to complete the partial, or do you simply make sure to complete the filling of the rx within 72 hours and leave it in the waiting bin?

The patient (and you) have 72 hours to finish the fill (including handover). After 72 hours, the quantity and handover for any reason is then void for that prescription. For all of these above reasons, it's NOT usual for a pharmacist to make the effort. You are to adjust after 72 hours to the actual quantity dispensed (in AZ, you are also to notate what actually was dispensed either from the prescription attachment or hand notated). This is 21 CFR 1304A:
https://www.deadiversion.usdoj.gov/21cfr/cfr/1306/1306_13.htm

Emergency dispensing for the federal standard is any situation that the PHARMACIST (not the physician) deems an emergency (see 21 CFR : 1300). That's a rather broad interpretation, but the practical one is whether or not you can convince the field office.

https://www.deadiversion.usdoj.gov/fed_regs/rules/2008/fr0627.pdf#search=emergency dispense

Also, that's a situation that both the Field and the Central DEA offices have upheld that a pharmacist may refuse for lack of supply or lack of confidence to receive supply in time for a dispense. The patient is SoL and another prescription has to be written.

Furthermore, federal law does have a specific exception for terminal illness that has some really far-reaching effects:
1. Call in prescriptions are valid for them
2. Partial fills are valid for them
3. Fax prescriptions are valid for them

You are required to keep documentation on the matter, but it's quite a standard problem.

AZ's MPJE always has the terminal patient questions as the Board gets a bunch of complaints about it from the Field Office. It's one of the few issues that VA has with the local pharmacies not respecting the rules for patients that we are doing fee-hospice for.

 

[Claydoe]

The patient (and you) have 72 hours to finish the fill (including handover). After 72 hours, the quantity and handover for any reason is then void for that prescription. For all of these above reasons, it's NOT usual for a pharmacist to make the effort. You are to adjust after 72 hours to the actual quantity dispensed (in AZ, you are also to notate what actually was dispensed either from the prescription attachment or hand notated). This is 21 CFR 1304A:
https://www.deadiversion.usdoj.gov/21cfr/cfr/1306/1306_13.htm

Emergency dispensing for the federal standard is any situation that the PHARMACIST (not the physician) deems an emergency (see 21 CFR : 1300). That's a rather broad interpretation, but the practical one is whether or not you can convince the field office.

https://www.deadiversion.usdoj.gov/fed_regs/rules/2008/fr0627.pdf#search=emergency dispense

Also, that's a situation that both the Field and the Central DEA offices have upheld that a pharmacist may refuse for lack of supply or lack of confidence to receive supply in time for a dispense. The patient is SoL and another prescription has to be written.

Furthermore, federal law does have a specific exception for terminal illness that has some really far-reaching effects:
1. Call in prescriptions are valid for them
2. Partial fills are valid for them
3. Fax prescriptions are valid for them

You are required to keep documentation on the matter, but it's quite a standard problem.

AZ's MPJE always has the terminal patient questions as the Board gets a bunch of complaints about it from the Field Office. It's one of the few issues that VA has with the local pharmacies not respecting the rules for patients that we are doing fee-hospice for.

https://www.deadiversion.usdoj.gov/fed_regs/rules/2008/fr0627.pdf#search=emergency dispense doesn't say anything about the handover it just says the fill. Is there anywhere where "the filling" has been concretely defined as not only filling the prescription but also the patient picking up? My original interpretation was that it had to be picked up within 72 hours, but the other pharmacist I work with said she interprets it as it merely has to be filled and they can pick it up whenever.

 

[zelman]

https://www.deadiversion.usdoj.gov/fed_regs/rules/2008/fr0627.pdf#search=emergency dispense doesn't say anything about the handover it just says the fill. Is there anywhere where "the filling" has been concretely defined as not only filling the prescription but also the patient picking up? My original interpretation was that it had to be picked up within 72 hours, but the other pharmacist I work with said she interprets it as it merely has to be filled and they can pick it up whenever.

From https://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_manual.pdf :

Partial Dispensing

A prescription for a schedule II controlled substance may be partially dispensed if the pharmacist is unable to supply the full quantity of a written or emergency oral (telephone) prescription, provided the pharmacist notes the quantity supplied on the front of the written prescription, on a written record of the emergency oral prescription, or in the electronic prescription record. The remaining portion may be dispensed within 72 hours of the first partial dispensing. However, if the remaining portion is not or cannot be filled within the 72 hour period, the pharmacist must notify the prescribing practitioner. No further quantity may be supplied beyond 72 hours without a new prescription.

 

[Claydoe]

From https://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_manual.pdf :

Partial Dispensing

A prescription for a schedule II controlled substance may be partially dispensed if the pharmacist is unable to supply the full quantity of a written or emergency oral (telephone) prescription, provided the pharmacist notes the quantity supplied on the front of the written prescription, on a written record of the emergency oral prescription, or in the electronic prescription record. The remaining portion may be dispensed within 72 hours of the first partial dispensing. However, if the remaining portion is not or cannot be filled within the 72 hour period, the pharmacist must notify the prescribing practitioner. No further quantity may be supplied beyond 72 hours without a new prescription.

Thanks for finding this appreciate it!

 

[Sine Cura]

TBH I couldn't give a rat's ass what the VA thinks. Why put a burden on a chain pharmacist to care? Every hospice patient I've dispensed for at CVS I got a written order.